If You Can Measure It, You Can Manage It Measuring Periodontal Status to Benefit Your Professional Well-Being

Common Issues for Clinicians How is periodontal status described in terms of disease severity and extent? How is periodontal status described in terms of disease severity and extent? How has periodontal status changed over time? How has periodontal status changed over time? Has it improved? Has it improved? Has it worsened? Has it worsened? Has it remained stable? Has it remained stable? Did periodontal status improve following treatment? Did periodontal status improve following treatment? Was treatment successful? Was treatment successful?

The Value of Measurement Periodontist Periodontist Self-knowledge of treatment effectiveness for decision-making Self-knowledge of treatment effectiveness for decision-making Informing the patient including explaining changes in periodontal status Informing the patient including explaining changes in periodontal status Informing the referring general dentist Informing the referring general dentist General dentist General dentist Self-knowledge of treatment effectiveness for decision-making including determining when to refer to a periodontist Informing the patient including explaining changes in periodontal status

Existing Measurement Method AAP Description AAP Description Severity: Severity: Slight: CAL* 1-2 mm Slight: CAL* 1-2 mm Moderate: CAL 3-4 mm Moderate: CAL 3-4 mm Severe: CAL ≥5 mm Severe: CAL ≥5 mm Extent: Extent: Localized: ≤30% of sites Localized: ≤30% of sites Generalized: >30% of sites Generalized: >30% of sites Clinical Practice Clinical Practice Periodontal charting is not consistently done in general practices Pocket depth rather than CAL is measured 168 pocket depth measurements are needed for a 28-tooth dentition Radiographs are also utilized *The AAP defines CAL as clinical attachment loss, where other authors define CAL as clinical attachment level

Interpreting Clinical Measurements How do dentists determine and describe the periodontal status of one site? How do dentists determine and describe the periodontal status of one site? How do dentists determine and describe the periodontal status of 28 teeth (or 168 sites)? How do dentists determine and describe the periodontal status of 28 teeth (or 168 sites)? How do dentists describe periodontal status change for a 28-tooth dentition, considering that How do dentists describe periodontal status change for a 28-tooth dentition, considering that <10% of sites may worsen <10% of sites may worsen Some sites may improve Some sites may improve >90% of sites typically are unchanged >90% of sites typically are unchanged

Periodontal Status for 1 Site How are 5 choices selected from Health, Gingivitis, and Mild, Moderate, and Severe Periodontitis used to fill 9 cells in the table? How are 5 choices selected from Health, Gingivitis, and Mild, Moderate, and Severe Periodontitis used to fill 9 cells in the table? Pocket Depth <5 mm 5-7 mm >7 mm Bone Height (CEJ to bone crest) >4 mm 2-4 mm < 2 mm

PreViser’s Method for 1 Site *Health is distinguished from gingivitis by bleeding on probing *Health is distinguished from gingivitis by bleeding on probing Pocket Depth <5 mm 5-7 mm >7 mm Radiographic Bone Height (CEJ to bone crest) >4 mm Moderate Periodontitis Severe Periodontitis SeverePeriodontitis 2-4 mm Mild Periodontitis Moderate Periodontitis Severe Periodontitis < 2 mm Health or Gingivitis* Mild Periodontitis Moderate Periodontitis

The Multiple Site Dilemma For the examples of site-severity listed in the table, can you describe and rank by severity and extent? For the examples of site-severity listed in the table, can you describe and rank by severity and extent? Site Example1234 A Severe Periodontitis Moderate Periodontitis B Severe Periodontitis Mild Periodontitis C Moderate Periodontitis Mild Periodontitis D Severe Periodontitis Moderate Periodontitis Mild Periodontitis

The PreViser Solution Even if you found this example easy, 70 examples are possible for 4 sites, 35,960 examples exist when each tooth counts as 1 site in a 28-tooth dentition, and 1,000 times this number when all 168 sites are used Even if you found this example easy, 70 examples are possible for 4 sites, 35,960 examples exist when each tooth counts as 1 site in a 28-tooth dentition, and 1,000 times this number when all 168 sites are used Site Example1234 Gen mod to sev (82) Severe Periodontitis Moderate Periodontitis Gen mild to sev (87) Severe Periodontitis Mild Periodontitis Gen mild to mod (26) Moderate Periodontitis Mild Periodontitis Gen mod to sev (92) Severe Periodontitis Moderate Periodontitis Mild Periodontitis

Conclusions There is no evidence that periodontal status is determined consistently and accurately by dentists There is no evidence that periodontal status is determined consistently and accurately by dentists There is no simple way to describe small changes whether comparing the periodontal status of one patient over time or two patients regardless of time-frame There is no simple way to describe small changes whether comparing the periodontal status of one patient over time or two patients regardless of time-frame No method is used that describes periodontal status numerically No method is used that describes periodontal status numerically

PreViser’s Solution OHIS™ calculates a score that is representative of the severity and extent of periodontal disease based on the deepest pocket and greatest bone loss for each sextant OHIS™ calculates a score that is representative of the severity and extent of periodontal disease based on the deepest pocket and greatest bone loss for each sextant The method is objective and hence consistent The method is objective and hence consistent The use of ranges for pocket depth and bone height reduces the error margin from inaccurate measurement The use of ranges for pocket depth and bone height reduces the error margin from inaccurate measurement The score ranges from 1 for health to 100 for severe periodontitis The score ranges from 1 for health to 100 for severe periodontitis A numeric score simplifies comparisons, explanations, and the creation of treatment guidelines including referral to a periodontist A numeric score simplifies comparisons, explanations, and the creation of treatment guidelines including referral to a periodontist The PreViser scoring system can be used to determine treatment effectiveness The PreViser scoring system can be used to determine treatment effectiveness

OHIS™ Disease Score Severity Text Nomenclature 1HealthHealth 2-3GingivitisGingivitis 4-10BeginningPeriodontitis Localized Beginning Periodontitis Generalized Beginning Periodontitis 11-36ModeratePeriodontitis Localized Beginning and Moderate Periodontitis Localized Moderate Periodontitis Generalized Beginning to Moderate Periodontitis Generalized Beginning and Localized Moderate Periodontitis Generalized Moderate Periodontitis SeverePeriodontitis Localized Beginning and Severe Periodontitis Localized Moderate and Severe Periodontitis Localized Severe Periodontitis Generalized Beginning to Severe Periodontitis Generalized Beginning and Localized Severe Periodontitis Generalized Moderate to Severe Periodontitis Generalized Moderate and Localized Severe Periodontitis Generalized Severe Periodontitis Courtesy PreViser Corporation, all rights reserved

PreViser Determines Risk, Too When dentists determine risk for periodontal disease, they use their subjective clinical judgment When dentists determine risk for periodontal disease, they use their subjective clinical judgment The PreViser method uses a standardized objective means The PreViser method uses a standardized objective means

Risk Calculator Score = 3 Practitioner evaluation over- estimating risk by 2 scores Practitioner evaluation under- estimating risk by 1 score Practitioner evaluation over- estimating risk by 1 score Practitioner evaluation under- estimating risk by 2 scores Risk Assessment by Subjective Judgment* Courtesy PreViser Corporation, all rights reserved * Persson et al. J Am Dent Assoc 2003 Subjective judgment is not reliably accurate Previser Founder’s Expert Periodontists 5 Patient Evaluations per data point General Dentist

PreViser Risk Assessment* Mean Bone Loss Risk 5 Risk 4 Risk 3 Risk 2 A measure of disease severity Courtesy PreViser Corporation, all rights reserved * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003

PreViser Risk Assessment* % of Sites with Bone Loss A measure of disease extent Courtesy PreViser Corporation, all rights reserved * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Year 3Year 9Year 15 Mean % (±SE) Tooth Loss Risk 5 Risk 4 Risk 3 Risk 2 PreViser Risk Assessment* Mean Tooth Loss Courtesy PreViser Corporation, all rights reserved * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Year 3Year 9Year 15 % of subjects Risk 5 Risk 4 Risk 3 Risk 2 PreViser Risk Assessment* % of Subjects with Tooth Loss Courtesy PreViser Corporation, all rights reserved * Page et al. J Am Dent Assoc 2002, J Clin Periodontol 2003

The PreViser Solution The PreViser risk and disease scores provide a means to document and explain a patient’s periodontal status in easily understood terms. Additionally the graph displays changes in status to determine if the patient’s status is stable, improving, or worsening. Risk score: 4 Disease State: 64 Courtesy PreViser Corporation, all rights reserved

Treatment Implications of Risk If risk is low, then treatment may not be required, as disease is not expected to progress If risk is low, then treatment may not be required, as disease is not expected to progress If risk is high, then treatment is required, as disease is expected to progress to a more advanced and possibly terminal stage If risk is high, then treatment is required, as disease is expected to progress to a more advanced and possibly terminal stage Hence, every patient receiving aggressive periodontal treatment has been determined to be high risk Hence, every patient receiving aggressive periodontal treatment has been determined to be high risk Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established when all patients are high risk Furthermore, a standard treatment protocol for a specific periodontal diagnosis can be established when all patients are high risk Are all patients at high risk for periodontal disease? Are all patients at high risk for periodontal disease? Courtesy PreViser Corporation, all rights reserved

With advancing age the prevalence of gingivitis decreases and periodontitis increases, which has been interpreted that risk for periodontitis is high. Prevalence of Periodontitis, 1950’s* * Marshall-Day et al, J Periodontol 1955 Gingivitis Periodontitis Tooth loss

Are all patients high risk for periodontal disease? Using the NHANES III database, Albandar, et al (J Periodontol 1999; 70: 13-29) reported the prevalence of Periodontitis in the adult population (30 years and older) Using the NHANES III database, Albandar, et al (J Periodontol 1999; 70: 13-29) reported the prevalence of Periodontitis in the adult population (30 years and older) 65% were Healthy or had Gingivitis 65% were Healthy or had Gingivitis 22% had Mild Periodontitis 22% had Mild Periodontitis 13% had Moderate to Severe Periodontitis 13% had Moderate to Severe Periodontitis When the same data is viewed by age cohort, … When the same data is viewed by age cohort, … Courtesy PreViser Corporation, all rights reserved

Periodontal Disease Risk Age Cohort % of Age Cohort Periodontitis Linear trend line Risk to remain healthy is 40% Risk for Periodontitis is 60% Courtesy PreViser Corporation, all rights reserved

Periodontal Disease Risk, Cont Age Cohort % of Age Cohort Linear trend line Moderate to Severe Periodontitis Mild Periodontitis Risk for Mild Periodontitis is 35% Risk for Moderate to Severe Periodontitis is 25% Courtesy PreViser Corporation, all rights reserved

Distribution of Risk for Periodontitis Courtesy PreViser Corporation, all rights reserved

Incorporating Risk Concepts into Treatment Planning Risk is the fundamental principle that can be used to justify the intensity and aggressiveness of treatment where a diagnosis of disease can be made Risk is the fundamental principle that can be used to justify the intensity and aggressiveness of treatment where a diagnosis of disease can be made Low risk means that disease is unlikely to progress and justification for treatment is minimally supported Low risk means that disease is unlikely to progress and justification for treatment is minimally supported High risk means that disease is likely to progress and justification for treatment is maximally supported High risk means that disease is likely to progress and justification for treatment is maximally supported Risk can be used to determine preventive interventions Risk can be used to determine preventive interventions Courtesy PreViser Corporation, all rights reserved

Remaining Healthy Withholding preventative treatment from healthy, at-risk patients denies them the opportunity to remain healthy and prevent complex reparative treatment 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% < >59 Age Cohort % of Age Cohort Healthy, no risk Healthy, at-risk Periodontitis Courtesy PreViser Corporation, all rights reserved

Summary An accurate determination of risk and its change over time is required to properly and dynamically plan treatment for periodontitis An accurate determination of risk and its change over time is required to properly and dynamically plan treatment for periodontitis An accurate determination of periodontal status including its change over time is required to dynamically establish proper treatment recommendations An accurate determination of periodontal status including its change over time is required to dynamically establish proper treatment recommendations OHIS™ provides a simple and accurate method to document risk, disease status and any changes that occur OHIS™ provides a simple and accurate method to document risk, disease status and any changes that occur Courtesy PreViser Corporation, all rights reserved

Managing Periodontitis Patients When treatment is initiated during the early stages of disease, success is more likely, treatment is more conservative, and fewer teeth are lost When treatment is initiated during the early stages of disease, success is more likely, treatment is more conservative, and fewer teeth are lost Risk predicts the future severity of disease Risk predicts the future severity of disease Most patients are referred when disease is severe resulting in more tooth loss and treatment that is complex and expensive Most patients are referred when disease is severe resulting in more tooth loss and treatment that is complex and expensive Treatment including the need for referral to a periodontist should be based on risk and disease Treatment including the need for referral to a periodontist should be based on risk and disease

Managing Patients With Periodontal Disease Disease State Severe Periodontitis Moderate Periodontitis Mild Periodontitis GingivitisHealth Very Low Moderate High Very Very Low Moderate High Very Low High Low High Risk Level Risk Level Treatment including the need for referral to a periodontist should be based on risk and disease where color coded cells identify treatment needs in increasing order: dark green, light green, yellow, and red Courtesy PreViser Corporation, all rights reserved